Anaesthesia and Intensive Care最新文献

Postoperative complications increase morbidity and mortality. With an ever-increasing number of older and more frail patients requiring surgery, the demand for effective postoperative care is escalating. Currently, there is a notable disparity between postoperative ward-based care and the care provided in high dependency units (HDUs) and intensive care units (ICUs). This gap exposes intermediate-risk patients, with limited access to HDU/ICU facilities, to an increased risk of postoperative morbidity and mortality and has significant health economic implications. Mounting evidence supports preventive approaches, including the use of specialised, anaesthesia-led postoperative care delivered in enhanced care units (ECUs) which can bridge this gap effectively. Anaesthetists have a critical role in delivering enhanced perioperative care and are ideally positioned to lead this transformative approach. Current traditional ward-based approaches identify patient deterioration after it has occurred, exposing patients to avoidable hypotension and hypoxia and potentially non-specific treatment modalities such as intravenous fluid therapy for hypotension and low-flow nasal oxygen for hypoxia. Strategies for reducing early postoperative morbidity and mortality following surgery must focus on implementing policies which enhance perioperative care systems tailored to the unique pathophysiology of the postoperative period. Appropriate effector responses ideally would treat these perturbations before they occur or rapidly after identification using tailored therapeutic strategies specific to an individual patient's physiology. In this commentary, we highlight key aspects of postoperative pathophysiology that support the call for increasing access to appropriate postoperative care facilities, and offer ECUs as one scalable solution.

Critical care patients require continuous monitoring of vital signs and test results, yet efficiently collecting and using this data poses challenges in the intensive care unit (ICU). Usability limitations in electronic health records (EHRs) within critical care settings can delay access to essential information, potentially jeopardising patient safety. To address these issues, we developed a bedside display system that provides ICU staff with real-time, accurate access to critical data. Our system extracts and reorganises key ICU data from the existing EHR, thus avoiding costly and time-consuming upgrades. By automatically updating information such as laboratory results, blood gas analysis, lactate levels, ratio of partial pressure of arterial oxygen to fractional inspired oxygen, fluid balance and body temperature in real-time, the display allows rapid access to essential information for managing critically ill patients without the need for personal computer-based EHR logins. Post-implementation surveys with physicians, nurses and clinical engineers showed predominantly positive responses, recognising improvements in workflow and care quality. Survey results also highlighted the need for customising the display format to meet the unique requirements of each professional role, thereby maximising the system's effectiveness in critical care. This bedside display system offers four key benefits. It enhances data reliability during multidisciplinary rounds, enables physicians with busy schedules to access critical information efficiently, helps nurses detect changes in patient status early and allows a complete transition from paper-based to digital data collection. This approach offers a fresh perspective and has the potential to encourage further research into optimal information presentation methods in critical care settings.

Little evidence exists on the postoperative trajectory after paediatric orthopaedic surgery. Pain and behavioural disturbance can have short- and long-term impacts on children and their families. An improved understanding of procedure-specific postoperative trajectories can enhance recovery. The primary outcome was to examine the duration and severity of postoperative pain experienced by children undergoing 10 commonly performed orthopaedic procedures. Secondary outcomes include rates of behavioural disturbances, nausea and vomiting, and parental satisfaction. Parents of children were invited to participate via telephone and followed up regularly until pain, nausea and vomiting, and behavioural disturbances were at baseline. Children's pain scores were measured using a parental proxy numerical rating scale. Three hundred and thirty-five patients were recruited across 10 routine paediatric orthopaedic surgical groups. Most (93.1%) fracture pain resolved after two days but lengthened with metal insertion or in more complex procedures such as tibial fracture manipulations and slipped upper femoral epiphysis (SUFE) pinning. Rates of postoperative nausea (24%) and vomiting (8%) were low but increased with longer operations and opioid use. Most patients received non-opioid simple analgesia on discharge, except for the SUFE pinning group, who typically received opioids for two days postoperatively. Occurrence of behavioural disturbances correlated with pain severity across groups. Pain generally resolved within two days and was managed with simple analgesia. Regional anaesthetic techniques were underutilised. Increased regional use and potentially short-term opioid analgesia at home in the SUFE and tibial fractures cohorts have been recommended at our institution. Improvement to discharge information includes procedure-specific recommendations on regular simple analgesia and expected recovery trajectory.

Patients with fulminant respiratory failure may receive extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplantation (LTx). Historically, morbidity and mortality with this approach has been high. The aim of this study is to describe the current indications and identify patient characteristics that predict a successful outcome. We performed a retrospective audit including all patients referred and bridged to LTx with ECMO at Alfred Health over an 11-year period (between 1 January 2010 and 31 December 2020). Patient, clinical and donor characteristics were collected, and outcomes were compared with all lung transplant recipients over the same time period. Twenty-eight referrals for LTx were received and 25 patients on ECMO were ultimately added to the waiting list for LTx. Patients bridged with ECMO were comparatively young (mean age 30 years) compared with the non-ECMO group (mean age 52.4 years). Of the 25 on the waiting list, three died awaiting LTx. Median time from waiting list activation to LTx was seven (interquartile range (IQR) 2-16) days in the ECMO group, compared with 92 (IQR 38-218) days in the non-ECMO group (P < 0.001). Survival for the 22 patients bridged to LTx with ECMO was 95% at 30 days, 86% at one year and 64% at three years. There was no significant difference in median survival between the ECMO group versus the contemporaneous non-ECMO lung transplant recipients (P = 0.73). ECMO can be used successfully to bridge patients with end-stage lung disease to LTx. With adherence to stringent protocols and patient selection, ECMO can provide medium-term survival outcomes comparable to patients who did not require pre-LTx support.

A 40-year-old high functioning woman developed severe anaphylaxis to rocuronium immediately following induction for laparoscopic appendectomy. Circulation and oxygenation were rapidly restored, the operation was abandoned and a 2-day intensive care unit stay, intubated with an adrenaline infusion for upper airway swelling, followed. The abdominal condition resolved with conservative management over a 5-day inpatient stay. Despite apparent full recovery from anaphylaxis, after discharge she had difficulty resuming baseline activities of daily living. Ongoing profound neurogenic fatigue prevented return to professional duties for over a year. Cognitive dysfunction following rapid resuscitation from anaphylaxis was unexpected. This case report examines relevant literature.

Tracheal intubation over a flexible guide is an essential skill for those managing difficult airways in anaesthesia and critical care. However, there may be difficulty railroading the tube over the guide due to impingement of the tube bevel entering the larynx. This may lead to repeated intubation attempts, possible trauma, possible failed intubation and hypoxia if alternative ventilation is not ensured. In this prospective observational study, we investigated the effectiveness of tracheal intubation without impingement over a guidewire already in place. Our direct wire-guided intubation system consists of a modified reinforced silicone tracheal tube with a guide channel in its wall to accommodate a matched kink-resistant guidewire as the introducer. We studied 299 American Society of Anesthesiologists Physical Status classification 1-3 patients with a predicted low risk of difficult intubation. Significant impingement occurred in one patient due to a deep laryngeal fissure (0.3%, upper limit of 95% confidence interval 1.9%). Laryngeal tube transit was graded 'not difficult' in 284 patients (95%), and 'mildly difficult' in 14 (4.7%). Tube transit between oropharynx and glottis offered no resistance in 294 patients (98.3%) and mild resistance in five (1.7%). There were no oesophageal misplacements of the tube. Our system appears effective to facilitate guidewire-assisted tracheal intubation in patients at predicted low risk of difficult intubation when a guidewire is already in place. Further studies are required in patients with predicted difficult intubation.